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APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT r 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is horeby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is S made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin Local Health District. '' 9 14 u�a�vc� City �A Lot Size PM 1 Job Address r Address Phone Owner's Name Coniractor TQ ✓�� Cense No 53Phon A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ x _ IP P INSTALLATION.❑ w �,, SYSTEM REPAIR C],,,_ _ w OTHER El i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F UNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE T PE OF WELL PROBLEM AREA ` CONSTRUCTION SPECIFICATIONS [ _ El Industrial ❑ en Bottom ❑ Manteca - l ia. of Well Excavation Dia. of Well Casing Specifications D Domestic/Private ❑ G vel Pack ❑ Tracy t -Type of Casing P r .. Type of Grout I}.'"" FI Public Cl Ot r F1 Delta Depth of Grout Seal t g I'I Irrigation _.-A Fox. Depth I I Eastern Surface Seal installed by— Repair y Repair Work Done ❑ Type of P mp —H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material itop 50'1 r Depth r Material (Below 501 TYP.E OF SEPTIC WORK: NEW INSTALLATION 7CPAIR71DDITION I I DESTRUCTION I i 1No septic system permitted if public sewer is r� available within 200 fcyet� At Installation wi11 serve: Residence Commercial_ ther Numbervin of living units: umber of bedrooms 9 ' Character of soil to a depth of 3'feet: " Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal T ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED LIDistanNce`"to nearest— Well Foundation Property Line s SEEPAGE PITS 11 Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I*certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature { certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of,Caiif nia." —L• The applic st call. ail re n s.'Complete drawing on r rse side. /z — $ , 4.4 Signed X Title: P Date: FOR DEPARTMENT USE ONLY L- Area _ Application Accepted by Date Pit or Grout Inspe ' n Date Final Inspection by Data a r 'Additional_ Comments: —�*-❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 1124(REV.I/KS) EH 14-2B /